Homeowners/Dwelling Application

Transcription

1 Homeowners/Dwelling Application Applicant Occupation Date Of Birth Inspection Contact: Phone #: Insured Agency: Agency Address: Agent: Prior Carrier Expiring Premium Effective Date Expiration Date Effective Date (of this policy) INSURED LOCATION Unit# City State Zip County Mailing Address City State Zip COVERAGES/LIMITS OF LIABILITY Policy Form Occupancy HO-2 HO-3 HO-4 HO-5 HO-6 HO-8 DP-1 DP-3 Primary Secondary Secondary Rental Rental Builder s Risk Vacant Dwelling/(A&A HO6) Other Structures Personal Property Loss of Use Loss Assessment Personal Liability Medical Payments AOP Deductible If Rented - # of weeks per year? Wind Deductible Section If Vacant length of vacancy? Wind Deductible % Named Storm Option Exclude Wind Wind Only Yes Yes Yes RATING INFORMATION Year Built (*update chart below) # Families # Stories Sq. Footage Protection Class (9/10 requires supplemental app) Distance to Fire Hydrant(Feet) Distance to Fire Station (Miles) Was the dwelling gutted and completely remodeled? No Yes Does the dwelling include any live knob and tube wiring? No Yes Does the dwelling include any fuses? No Yes Does the dwelling include any lead piping as part of the plumbing system? No Yes *Update Information (required if year built is >35 years old) Roof (Year) Wiring (Year) Heating (Year) Plumbing (Year) 1 of 5

2 Construction Frame/Stucco Masonry Masonry Veneer Superior Log (supplemental app) EIFS Roof Type Shingles Asphalt Tile Metal Slate Shake-cement Shake-wood Other Roof Shape Hip Gable Flat Other Wind Credits Wind Resistive Glass Single Straps Double Straps Clips Metal Electronic Shutters Metal Manual Shutters Protection Credits Central Fire Central Burglar Smoke Detector Interior Sprinklers Gated Community Monitored Cameras LOSS HISTORY (prior 3 years) Date Type of Loss Cause Amount Open/Closed Preventative Measures ADDITIONAL UNDERWRITING INFORMATION Any trampoline on premises? No Yes Any swimming pool on premises? If yes, is pool fenced with locked gate? No Yes No Yes If yes, any slide or diving board? No Yes Any business on premises? If yes, explain in remarks section. No Yes Any insurance declined, cancelled or non-renewed within 5 years? No Yes Is there a daycare located on premises? No Yes Any animals on premises? If yes, please provide breed and bite history in remarks section. No Yes Is the dwelling for sale? No Yes Is the unit rented to students? No Yes Has anyone with financial interest in the property been convicted of arson, fraud or other crime related to a loss on property? If yes, please explain in remarks section. No Yes Has the insured declared bankruptcy, foreclosure or repossession in the last 5 years? No Yes Is the dwelling undergoing any renovation or construction? If yes, requires supplemental application. No Yes Is there a woodstove on premises? If yes, requires supplemental application. No Yes Is there a fuel tank on premises? If yes, Underground Basement Above Ground No Yes Is the dwelling on the National Historic Registry? If yes, tours? No Yes No Yes OPTIONAL COVERAGES LIMITS DEDUCTIBLE Personal Property Replacement Cost Yes No Extended Replacement Cost Yes No 25% 50% Water Backup Yes No $5K $10K $15K $25K Mold property limit Yes No $5K $10K $15K $25K Mold liability limit Yes No $5K $10K $15K $25K All Risk Coverage C (HO-3, HO-4, HO-6 Only, incl. w/ HO-5) Yes No Equipment Breakdown Yes No Earthquake on A&C Yes No Sinkhole (If yes, complete additional questions below) Yes No Personal Injury (primary occupancy only) Yes No Identity Fraud (primary occupancy only) Yes No 2 of 5

3 Ordinance or Law (10% automatically incl. for HO forms) Yes No 10% 15% 25% All Risk Coverage A (HO-6 Only) Yes No Extended Glass Breakage & Vandalism (not available on vacant risks) Yes No Increased Special Limits Yes No Golf Cart Physical Damage Coverage If yes, provide Year, Make, Model, Serial # & Yes No Value. Theft of Building Materials (COC/Renovations) Yes No Soft Costs Extension (COC/Renovations) Yes No CA Only: Is there 150 feet of brush clearance around all structures? Yes No CA Only: If Wood Shake roof, is there 1,000 feet of brush clearance? Yes No CA, NV, WA & OR: Is home located on a slope? If yes, degree of slope? Yes No If yes to EQ Coverage in CA, OR, WA: Has the dwelling been retrofitted and bolted to the foundation? Yes No If yes to Sinkhole: 1. Have you observed: (i) the signs of settling, cracking, bulging, sagging, bending, leaning, shrinkage or expansion of any part of the dwelling or other structure or (ii) any depression in the ground surface on the premises? Yes No 2. Have you been told, has it been disclosed to you or are you otherwise aware of: (i) a sinkhole that might affect the dwelling or other structures or (ii) any other partial or Yes No complete sinking or collapse of the dwelling or other structures? 3. At any time, has this property had any prior sinkhole claims? Yes No REMARKS/Additional Information Additional Insured (Name/Mailing Address) Grantor, Beneficiary or Trustee (For Named Insureds that are Trusts, Estates, etc.) Mortgagee (Name/Mailing Address) Loan # Mortgagee (Name/Mailing Address) Loan # 3 of 5

4 NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AN D MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTE MPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO KANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARED WITH KNOWEDLGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIAL FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMAT ION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365: , ). 4 of 5

5 NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE GUILTY OF A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECT S SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS : IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW. PRODUCER S SIGNATURE DATE: Applicant s Statement: The undersigned applicant declares that if the information supplied on this application changes between the date of this application and the time when the insurance policy is issued, the applicant will immediately notify the insurer of such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorizations or agreement to bind this insurance. The undersigned applicant further declares that I have read and understand the entire application and that the information provided is true, complete and correct to the best of my knowledge and belief. This information is being offered to the company as an inducement to issue the policy for which I am applying. APPLICANT S SIGNATURE DATE: 5 of 5